The document outlines the importance of documentation and communication in nursing, emphasizing the need for accurate and comprehensive client records. It highlights principles of charting, types of reports, and the significance of maintaining confidentiality in nursing documentation. Effective documentation is critical for ensuring continuity of care and minimizing errors.

1. FON
Nursing lecturer ; Momal Menghwar
BCNAHS
BSN II
Communication of the nursing
process documenting and reporting

2. Communication of the Nursing Process: Documenting and Reporting:
 Describe the purposes of the client record
 List the principles of charting
 Discuss the guidelines of documentation.
 Discuss the importance of confidentiality in the documenting
and reporting.

3. COMMUNIATION OF NP
 “Communication in nursing” defines exchanging
information, thoughts, and feelings among people
using speech or other means.The patient conveys their
fears and concerns to their nurse to help them make a
correct diagnosis.

4. Reports
 Are oral, written, or audiotape exchanges of information
between caregivers.
 Common reports
 Change-in-shift report
 Telephone report
 Telephone or verbal orders – only RN’s are allowed to accept
telephone orders.
 Transfer report
 Incident report

5. Documentation
 Is anything written or printed that is relied on as record or proof for
authorized person.
 Nursing documentation must be:
 accurate
 comprehensive
 flexible enough to retrieve critical data, maintain continuity of care,
track client outcomes, and reflects current standards of nursing
practice
 Effective documentation ensures continuity of care saves time and
minimizes the risk of error.
 As members of the health care team, nurses need to communicate
information about clients accurately and in timely manner.

6. CLIENT RECORD
 The client record is a compilation of a client's health
information. Each health care institution agency has policies
that specify the nurse s documentation responsibility.

7. purposes of the client record
 A client's record should tell the story of the client's
health care condition
 should allow other health care providers to quickly
read .
 understand the patient's health concerns or
problems.

8. List the principles of charting
 Chart in the correct record.
 Chart promptly.
 Be accurate, objective, and complete.
 Track test results and consultation reports.
 Avoid repetitive copying and pasting
 Use approved abbreviations.
 Record instances of non-adherence.
 Document delegated tasks.
 afeguard patient healthcare records.

9. Thank You

10. Reference
 Erb, G., & Kozier, B. (1995). Fundamentals of Nursing:concepts,
process and practice.(5th Edition).Addison -Welsy